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STATE OF CALIFORNIA <br /> `Os <br /> STATE WATER RESOURCES CONTROL BOARD ' o <br /> RGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY I NEW PERMIT S RENEWAL PERMIT R!rS CHANGE OF INFORMATION O 7 PERM Y CLOSED <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PMCELA(OWIONAt) <br /> CITU NAME STATE ZIP COOS SITE PHONE•WITH AREA CODE <br /> V BOX S /CAr,• 1 CA S <br /> T NDCATE O CORPORATION O SONDUAL O PARTAER4HP a LOCAL-AGENCY O couNryAGENCY 0 STATEAGFNCY <br /> DISTRICTS (] FfU)ERALAGENCy <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIANRESERVATION <br /> A OF TANKS AT SITE E.P.A. I.D.N(cwwwI <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE+"WITH AREA CODE <br /> S <br /> NIGHTS:NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> R. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE CF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ibv bim"m IAOMDUAL [� LOCAL-AGENCY L� STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY El FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING OR STREET ADDRESS OMbowlem Q INDIVIDUAL Q =AL-AGENCY 0 STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP I3 GOUNTYAGENCY (]FEDEPALAWKY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916) 739-2582 if questions arise. <br /> TY(TK) HQF4 R4 - 0 2 7 3 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box IOa is checked. <br /> CHECK ONE BOX INDICATING WHICH A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L fl.[1] In. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MCINTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COLIN�/YY�NA JURISDICTION# FACILITY$ sp/u c O /D <br /> M /4 s-I a <br /> LOCATION CODE -OPTKHUL CENSUSTRACT0 -OP77ONAL SUPVISOR-DISTRICT CODE .OPTIDMAL <br /> U a <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE 0� INFO MATION 0 <br /> FORM A(490) _.z.. —'FOROttOAA2 <br />